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Laser trabeculoplasty should be considered in elderly glaucoma patients
Eliminating daily medications improves the quality of life of patients and their caregivers.
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Ophthalmologists will inevitably care for more senior patients for two reasons. The first reason is that life expectancy continues to increase, and the second is that the baby boomer era will enter the senior age range. My personal understanding with this occurred when my wife, a geriatrician, pointed out one day that I saw patients who were on average older that the patients she saw.
Savak Teymoorian
One issue we commonly discuss is the problem of polypharmacy in these senior patients. As physicians, we are good at adding more medications, including eye drops, but bad at taking them away. This problem, however, provides us an opportunity to help our senior patients, including those who are clearly nearing the end of life. It is common for our patients to express that they are more scared of being blind than the actual death process. They are willing to put in as many drops as needed to preserve their vision, even if it negatively influences their quality of life. At this stage in life, minimizing the physical and mental burden from medications and maximizing quality of life become a priority. Either selective or argon laser trabeculoplasty provides a useful and low-risk method to accomplish these goals.
Consider the following three cases:
- Ashley, your 80-year-old female patient whom you have been caring for the last few years for ocular hypertension on a single agent, presents to your office. Although her glaucoma is controlled, she is having issues with drops. This includes difficulty remembering, either because of the many medications she takes every day or because of declining cognitive state such as early dementia. She finds that actually executing the task of getting her drops in is hard because of arthritis in the hand or cervical spine. She also has problems affording the drops because of the cost burden from all of her other medications. One simple answer to all of these issues is providing SLT or ALT treatment to replace the single drop altogether. This would create a happier, more compliant patient.
- Brian, your new senior patient at 65 years old, presents to your office and is diagnosed with mild to moderate glaucoma that requires the initiation of a single glaucoma agent. Given the average life expectancy of approximately 80 years for men in the U.S., you anticipate he will need one or more decades of glaucoma care. One option would be to start glaucoma drops with a single agent. Superficially, it does not appear to be much with one or two drops a day. However, you then consider how this choice would create a burden and negative influence on his quality of life. You review his chart and see he is already on one hypertensive medication, one cholesterol pill and a medication for some other disease, such as his prostate. In addition, this new medication you are considering needs to be administered topically, and you find out Brian has never put anything near his eyes. Lastly, you are concerned about the possible systemic side effects he may experience from the medication. Instead, you elect to perform laser trabeculoplasty therapy to circumvent these issues. He is thrilled because he does not have to deal with instilling drops, and you are satisfied because you have eliminated any new obstacles he would have faced by starting drops.
- Ken, your pleasant but moderately to severely demented 70-year-old patient, is brought in by his caregiver and family member to the office. You expect his life expectancy to be long because he is otherwise healthy; however, the daily application of eye drops is a chore, which is repeatedly stated by those accompanying him. They say sometimes it takes three people to administer one drop at night because he becomes physically aggressive and does not comprehend the need for the drops. One option for this patient would be to consider SLT. Although this would require compliance by Ken to sit for a few minutes at the laser, which is possible earlier in the day, your experienced hand can get this done with minimal discomfort and time. In particular, you decide on SLT instead of ALT because you believe that he may need repeat treatment in the future given the extended amount of life you predict for his age. This decision would save his caregivers and family members much daily grief by no longer needing to administer the drops. More importantly, this saves Ken from unnecessary everyday anxiety from getting his drops and improves his quality of life.
Improving the quality of life for both our elderly patients and those caring for them becomes a priority given our increasing number of elderly patients. The use of laser trabeculoplasty provides a tool to medically treat glaucoma, decreases the burden and cost of eye drops, reduces the associated stress of family and caregivers administering these drops, and helps minimize anxiety in patients. Next time, consider the use of laser trabeculoplasty in your elderly glaucoma patients.
For more information:
Savak Teymoorian, MD, MBA, can be reached at Harvard Eye Associates, 24401 Calle de la Louisa, Suites 300-312, Laguna Hills, CA 92653; email: steymoorian@harvardeye.com.Disclosure: Teymoorian reports he is a consultant for Allergan, Glaukos and MDbackline.com and is a speaker for Bausch + Lomb.